Fill and Sign the 2019 California Form 3525 Substitute for Form W 2 Wage and Tax Statement or Form 1099 R Distributions from Pensions Annuities

STATE OF WASHINGTON DEPARTMENT OF FINANCIAL INSTITUTIONS SECURITIES DIVISION PO Box 9033 Olympia, WA 98507-9033 (360) 902-8760 FOR VALIDATION ONLY 001-080-238-0001 FRANCHISE REGISTRATION APPLICATION APPLICATION FOR (check only one): FILE NO. REGISTRATION OF AN OFFER OR SALE OF FRANCHISES — $600.00 _________________________________________________ REGISTRATION RENEWAL STATEMENT OR ANNUAL REPORT — $100.00 _________________________________________________ POST-EFFECTIVE AMENDMENT#__________ ______________________________________________________ INSERT FILE NO. OF PREVIOUS FILINGS OF APPLICANT, IF ANY FEE (To be enclosed by applicant at time application is initially filed) DATE OF APPLICATION PRE-EFFECTIVE AMENDMENT # __________ 1. NAME OF FRANCHISOR _______________ ________________________________________________________ DBA (if applicable ___________________________________________________________________________ NAME UNDER WHICH THE FRANCHISOR IS DOING OR INTENDS TO DO BUSINESS ___________________ ______________________________________________________________________________________________ 2. FRANCHISOR’S PRINCIPAL BUSINESS ADDRESS __________________________________________________ ______________________________________________________________________________________________ TELEPHONE NUMBER __________________________________________________________________________ 3. NAME OF PERSON TO WHOM COMMUNICATIONS REGARDING THIS APPLICATION SHOULD BE DIRECTED ____________________________________________________________ ________________________ ADDRESS _____________________________________________________________________________________ TELEPHONE NUMBER __________________________________________________________________________ 4. NAME OF FRANCHISOR’S AGENT AUTHORIZED TO RECEIVE PROCESS _____________________________ _____________________________________________________________________________________________ ADDRESS ____________________________________________________________________________________ IN THE STATE OF ______________________________________________________________________________ 5. NAME OF SUBFRANCHISOR’S, IF ANY FOR THIS STATE ____________________________________________ ______________________________________________________________________________________________ ADDRESS _____________________________________________________________________________________ TELEPHONE NUMBER __________________________________________________________________________ SC-610-225 FRANCHISE APP (R/7/5 Page 1 of 7 UNIFORM CONSENT TO SERVICE OF PROCESS KNOW ALL MEN BY THESE PRESENTS: That the undersigned,_____________________________________________________________________________ (a corporation) (a partnership) organized under the laws of the state of _________________________________ (an individual) (_________________________________), for the purpose of complying with the laws of the state of Washington relating to the registration, exemption from registration or sale of franchises, hereby irrevocably appoints the Administrator of Securities, and the successors in such office, its attorney in the state of Washington upon whom may be served any notice, process, or pleading in any action or proceeding against it arising out of or in connection with the sale of franchises, or out of violation of the aforesaid laws of said state; and the undersigned does hereby consent that any such action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue within said state by service of process upon said officer with the same effect as if the undersigned was organized or created under the laws of said state and had lawfully been served with process in said state. It is requested that a copy of any notice, process, or pleading served hereunder by mailed to (Name and Address: _________________________________________________________________________________________ DATED: _________________________________________________ _________________________________________________________ Signature BY: _____________________________________________________ TITLE: ____________________________________________________ SEAL _________________________________________________________ Signature BY: _____________________________________________________ TITLE: ___________________________________________________ SC-610-225 FRANCHISE APP (R/7/5 Page 2 of 7 CORPORATE ACKNOWLEDGMENT STATE OF ______________________ ss COUNTY OF ____________________ On this ______ day of ________, 20 ___, before me personally appeared ___________________________ to me known personally to be the (president, vice president, secretary, treasurer, or other authorized officer or agent, as the case may be) of the corporation that executed the within and foregoing instrument, and acknowledged said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that s/he was authorized to execute said instrument and that the seal affixed in the corporate seal of said corporation. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. ___________________________________________________ NOTARY PUBLIC NOTARIAL SEAL SC-610-225 FRANCHISE APP (R/7/5 Page 3 of 7 MY COMMISSION EXPIRES ___________________________ INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGMENT STATE OF ______________________ ss COUNTY OF ____________________ On this _________ day of _____________, 20___, before me _________________________________ the undersigned officer, personally appeared _______________________________________________ to me personally known and known to me to be the same person(s) whose name(s) is (are) signed to the foregoing instrument, and acknowledged the execution thereof for the uses and purposes therein set forth. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. __________________________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES: __________________________ NOTARY SEAL SC-610-225 FRANCHISE APP (R/7/5 Page 4 of 7 SIGNATURE PAGE I certify under penalty of law that I have read this application and the exhibits attached hereto and incorporated herein by reference, and know the contents thereto and incorporated herein by reference, and know the contents thereof and that the statements therein are true and correct to the best of my knowledge. Executed at ____________________________, _________________________________, 20 _____. SIGNATURE(S) OF FRANCHISOR AND/OR SUBFRANCHISOR __________________________________ __________________________________________________________ SEAL BY _______________________________________________________ TITLE ____________________________________________________ STATE OF ______________________ SS COUNTY OF ____________________ Personally appeared before me this ______ day of ________________________, 20 _____, the above named ___________________________________, (and) ___________________________________, to me known to be the person(s) who executed the foregoing application (as __________________________ and applicant) and (each), being first duly sworn, stated upon oath that said application, and all exhibits submitted herewith, are true and correct. __________________________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES ________________________ NOTARY SEAL SC-610-225 FRANCHISE APP (R/7/5 Page 5 of 7 SUPPLEMENTAL INFORMATION PAGE 1. List the following: a. b. c. d. e. The states in which this proposed registration is effective The states in which this proposed registration is or will be shortly on file. The states, if any, which have refused, by order or otherwise, to register these franchises. The states, if any, which have revoked or suspended the right to offer these franchises. The states, if any, in which the proposed registration of these franchises has been withdrawn. 2. With respect to all franchises sought to be registered set forth, in budget form, the total projected financing required by franchisor to fulfill the franchisor ’s obligations to provide real estate, improvements, equipment, inventory, training and all other items included in the offering. Show separately the sources of all of the required funds including any proposed loans or contributions to capital. SC-610-225 FRANCHISE APP (R/7/5 Page 6 of 7 FRANCHISE ACT INTERPRETIVE AND POLICY STATEMENTS Table of Contents INTERPRETIVE STATEMENTS Stmt. No. Topic FIS-01 FIS-02 FIS-03 Subfranchisor Registration Requirements Restrictions on Transfer of Franchises RCW 19.100.180(2) (j) — Termination of a Franchise, RCW 19.100.180(1), RCW 19.100.180(2) (c) Arbitration Site, RCW 19.100.180(1) RCW 19.100.030(4) (b) (ii) and (iii), Trade Shows and Advertising FIS-04 FIS-05 POLICY STATEMENTS FPS-01 FPS-02 FPS-03 FPS-04 FPS-05 FPS-06 Franchisor/Franchisee Relationship disclosure Requirements, RCW 19.100.180 RCW 19.100.250 & 19.110.180 — Requests for Interpretive and No-Action Letters RCW 19.100.050, Surety Bonds In Lieu of an Impound Franchise Broker License Effective Period Filing Date Determination Franchise Broker Registration SC-610-225 FRANCHISE APP (R/7/5 Page 7 of 7